Cataract surgery is usually performed with the patient in the supine position. However, many elderly patients or those with certain medical conditions cannot assume the supine position for various reasons. Furthermore, given the option, most patients prefer to be slightly elevated during cataract surgery.
Main causes of difficulty with supine position:
Spine/skeletal diseases: Ankylosing spondylitis, kyphosis, and other degenerative spinal diseases
Cardiopulmonary diseases: Heart failure with orthopnea, severe chronic obstructive pulmonary disease
Motor dysfunction: Patients who have difficulty transferring from a wheelchair
Surgery for patients who cannot tolerate the supine position may increase the risk of surgical complications, so adequate preparation is necessary to maintain comfort for both the patient and the surgeon.
QIs it possible to perform cataract surgery on patients who cannot tolerate the supine position?
A
Yes, it is possible. With appropriate positioning and microscope preparation, safe cataract surgery can be performed even for patients who cannot assume the supine position. However, the risk of complications may be higher compared to standard supine surgery, and thorough preoperative explanation to the patient is necessary.
The method for managing patients who cannot tolerate the supine position is selected from the following three options depending on the situation.
① Trendelenburg Position
Indications: Patients with spinal or neck deformities who can be tilted backward as a whole (e.g., ankylosing spondylitis, kyphosis).
Method: Tilt the patient backward while seated so that the feet are higher than the head.
Precautions: Venous congestion may occur due to the head being lower. Compensate for vitreous bulge or increased posterior chamber pressure by adjusting the infusion bottle height.
Prerequisite: Useful for surgeons whose microscope cannot tilt forward. Not suitable for patients with orthopnea.
②Upright sitting position (surgeon standing)
Indications: Patients who cannot lie flat but can extend the neck (e.g., those with orthopnea but flexible spine).
Method: Seat the patient upright, adjust the headrest to extend the neck. The surgeon operates while standing.
Approach: The standing temporal approach is usually the easiest.
③Face-to-face upright sitting position
Indications: Patients who cannot lie flat and also cannot extend the neck (the most common difficulty with supine positioning).
Method: Seat the patient upright, tilt the microscope 40–60 degrees forward from vertical to face the eye. The surgeon sits (or stands) facing the patient.
Incision site: Place incisions in the lower half of the cornea. For a right-handed surgeon, a temporal incision (0 degrees) for the left eye and an inferior incision (270 degrees) for the right eye.
Topical-intracameral anesthesia is strongly recommended. Because the patient can look toward the microscope, the eye can be kept “on axis,” making surgery easier. This principle is particularly useful in face-to-face surgery.
In face-to-face surgery, the eye is positioned higher from the floor than in the usual supine position. To compensate, the infusion bottle height must be set higher than usual. Similarly, in the Trendelenburg position, the bottle height is increased to correct the rise in intraocular pressure due to venous engorgement.
QWhat incision sites are appropriate for face-to-face surgery?
A
The basic approach is to place the incision in the lower half of the cornea. For a right-handed surgeon, it is easiest to use a temporal incision (0 degrees) for the left eye and an inferior incision (270 degrees) for the right eye. However, if the patient can be positioned more supine or can turn the chin toward the microscope, more flexibility is possible.
Postoperative management for patients with difficulty maintaining a supine position involves the same observations as for standard cataract surgery, but attention must also be paid to systemic management due to underlying diseases (heart failure, chronic obstructive pulmonary disease).
Postoperative confirmation of respiratory status and circulatory dynamics
Monitoring of intraocular pressure
Surveillance for signs of infection (early detection of endophthalmitis)
6. Pathophysiology and detailed mechanism of onset
Sohail et al. reported a consecutive series of 240 cases of cataract surgery using face-to-face upright positioning, demonstrating that this technique is feasible for elderly patients with comorbidities (2018). Lee et al. also reported this approach in the Journal of Cataract & Refractive Surgery (2011).
In recent years, heads-up surgery (using a 3D visualization system) has been introduced, where the surgeon operates while viewing a surgical monitor. This technology eliminates constraints related to the angle of the microscope eyepiece and may facilitate face-to-face surgery for patients who have difficulty with the supine position.
Lee RM, Jehle T, Eke T. Face-to-face upright seated positioning for cataract surgery in patients who cannot lie flat. J Cataract Refract Surg. 2011;37(5):805-809. doi:10.1016/j.jcrs.2011.03.023. PMID:21511148.
Sohail T, Pajaujis M, Crawford SE, Chan JW, Eke T. Face-to-face upright seated positioning for cataract surgery in patients unable to lie flat: Case series of 240 consecutive phacoemulsifications. J Cataract Refract Surg. 2018;44(9):1116-1122. doi:10.1016/j.jcrs.2018.06.045. PMID:30078535.
